Running head: QI INITIATIVE: INCREASING STAFF PARTICIPATION IN N2NBSR

Quality Improvement Initiative: Increasing Staff Participation in Nurse-to-Nurse Bedside Shift Report (N2NBSR) Denise S. VanderWeele June 13, 2013 Ferris State University, NURS 440

QI INITIATIVE: INCREASING STAFF PARTICIPATION IN N2NBSR

Abstract Nurse-to-nurse bedside shift report (N2NBSR or bedside report) is a process that enhances patient-centered care and promotes patient safety (Studer, 2012). Bedside report has been shown to empower staff, improve patient involvement, and allow for a safe transition of care between providers (Reinbeck & Fitzsimons, 2013). Even with growing evidence that bedside shift report is of great benefit to the patient, the utilization of this tool of communication by nurses has been noted to be inconsistent nationwide (Sand-Jecklin & Sherman, 2012). A similar trend in this institution has prompted this quality improvement initiative. It is the goal of this initiative to identify barriers that prevent nurses from consistently giving shift report at the patients bedside, to obtain patient feedback about the effectiveness of including the patient in bedside report, and to develop a plan to prompt nurses to achieve 100% compliance in giving nurse-to-nurse shift report at the bedside.

QI INITIATIVE: INCREASING STAFF PARTICIPATION IN N2NBSR

Quality Improvement Initiative: Increasing Staff Participation in Nurse to Nurse Bedside Shift Report (N2NBSR) Establishing bedside nurse to nurse shift report (N2NBSR or bedside report) has been shown to empower staff, improve patient involvement and allow for a safe transition of care between providers (Reinbeck & Fitzsimons, 2013). Statistically, up to two-thirds of sentinel events in hospitals are related to communication problems, with nurse-to-nurse handover of patient care presenting a large risk for potential miscommunication (Sand-Jecklin & Sherman, 2013). Implementing shift report at the bedside aids nurses in meeting the patient safety goals of The Joint Commission (Revere & Eldridge, 2007) and the call for increased patient-centered care by the Institutes of Medicine (IOM, 2001). Most nurses at this institution are familiar with the rationale for bedside report due to the basic education presented when this process was initiated over a year ago. There is evidence, however, that bedside report is not being practiced consistently. Through a combination of surveys with patients and nurses as well as data on patient satisfaction and nurse compliance, this quality improvement initiative will attempt to identify the barriers to giving bedside report and provide strategies to overcome them. Consistent implementation of N2NBSR is expected to result in fewer errors, better patient-centered care and increased comfort for the nurses in delivering bedside report (Studer, 2012). The Need for Improvement in N2NBSR Staff members and Clinical Coordinators have noted a decrease in the frequency of nurses giving bedside shift report over the past several months. This was confirmed in recent minutes from the Unit Based Council meeting. (The UBC is a shared governance committee of staff nurses). Griffin (2010) suggests that continued follow-up and evaluation of the bedside

QI INITIATIVE: INCREASING STAFF PARTICIPATION IN N2NBSR report process is needed to allow for improvements and that changing the report process must not be a one-time educational opportunity. Nationally, inconsistent use of bedside report was found in all hospital inpatient units (Sand-Jecklin & Sherman, 2013). A literature search on barriers to giving bedside report provides a few clues as to why nurses may be resistant to changing the location and manner that they give report to the oncoming shift. The largest barrier for nurses was cited as the sacred cow phenomenon (Hagman, Oman, Kleiner, Johnson & Nordhagen, 2013). Nurses were accustomed to giving report at the nurses station, which allowed them to give emotional support and socialize with each other between shifts while they reported on their patients (Wakefield, Ragan, Brandt & Tregnago, 2012). Shifting to bedside report altered this socialization and support system. Another barrier noted was that nurses felt that the process was too time-consuming (Wakefield, Ragan, Brandt & Tregnago, 2012), especially when reporting off to more than one nurse or care team (Sand-Jecklin & Sherman, 2013). Some nurses were unsure what to say during report in front of the patient (Wakefield, Ragan, Brandt & Tregnago, 2012). Other concerns that nurses voiced were disturbing the patients sleep and having non-English speaking patients who would not understand the report (Hagman, Oman, Kleiner, Johnson & Nordhagen, 2013). In all the studies examined for this paper, the nurses expressed fear that patient confidentiality would be breached by giving report in front of family members or in a semiprivate room. Discovering the perceived barriers at our institution is an important step in the quality improvement process (Yoder-Wise, 2011). It is also necessary to obtain a benchmark for nurse compliance in delivering report at the bedside prior to initiating quality improvement measures.

QI INITIATIVE: INCREASING STAFF PARTICIPATION IN N2NBSR

From the data gathered, benchmarks will be established, a goal can be set for improvement, expected outcomes can be defined, and a plan of action can be determined, then evaluated. Quality Improvement Initiatives Begin with Leadership This project requires a transformational leader a person who can change the way nurses approach bedside report and inspire them to move toward the goal of a culture change that will result in stakeholder buy-in (Yoder-Wise, 2011). The project leaders task will be to assist the Q.I. (Quality Improvement) core group in discovering why compliance is low and assisting the group in exploring creative solutions to the problem. A transformational leader will encourage the group to implement change and engage other nurses in developing a new paradigm while exhibiting the desired behavior. In choosing a core group to address this initiative, members of the Unit Based Council (UBC) would be recruited because it is a shared governance council that addresses issues concerning nursing practice and evidence-based protocols within the nursing unit. The use of staff champions from a shared governance body such as the UBC is crucial to the continued success of bedside report (Hagman, Oman, Kleiner, Johnson & Nordhagen, 2013; and Wakefield, Ragan, Brandt & Tregnago, 2012). UBC members are stakeholders who have already expressed their commitment to the process of quality improvement. Being a part of the shared governance board indicates that they understand the need for innovation, the prevention of error, and the staff development necessary to continue the process of quality improvement (Yoder-Wise, 2011). Other valued members of the Q.I. group would be the nurse educator for this unit. She is responsible for education initiatives and would be a great resource for planning any education needed to support the Q.I. goals that will be established. The three Clinical Coordinators

QI INITIATIVE: INCREASING STAFF PARTICIPATION IN N2NBSR

(permanent charge nurses who are available for both day and night shifts) would complete the Q.I. core group. The Clinical Coordinators would report on data gathered from patients concerning bedside report. This data is already being gathered as a part of their daily patient rounding (Studer, 2012) and would be shared with the Q.I. group. They also have access to patient satisfaction scores and can correlate them to this initiative. Data Collection Data on nurse compliance, perceived barriers to giving bedside report and patient input will be gathered in by specific members of the Q.I. team. Selected team members will observe report time and record the number of patient reports given at the nurses station (e.g. out of 20 patients, six did not receive bedside report). This will be complied over a two week period to establish a baseline of compliance in which to measure outcomes against. Specific questions for the Clinical Coordinators to ask patients during their patient rounding will be: Did your nurses do bedside report during the last 24 hours? Were you included in the discussion? Were your concerns/needs addressed during or after this report? This data will be compiled over the same two week period. Patient satisfaction scores will also be reviewed and included for this time period. A questionnaire to be completed by the staff nurses concerning their perceived barriers to bedside report should provide some insight into why nurses are not doing bedside report for every patient, on every shift at this institution. The anonymous responses will allow the nurses the freedom to express their concerns without the risk of assigning blame. This will also assist the Q.I. committee in identifying and addressing the barriers that the nurses have to compliance and be the springboard for forming a plan to overcome them. The Q.I. team will develop, distribute and analyze this questionnaire.

QI INITIATIVE: INCREASING STAFF PARTICIPATION IN N2NBSR

From this data, a benchmark level of compliance will be established and strategies developed to move toward 100% compliance. Nurse concerns may be addressed by presenting the evidence supporting bedside report as a meaningful and worthwhile activity for both nurses and patients. Scripts or role-playing may need to be created to address concerns such as being unprepared or not knowing what to say at the bedside, how to do report with a non-English speaking patient, or how to handle a demanding patient who is interrupting the flow of report and prevention the nurse from completing it in a timely manner.. Patient concerns will also be addressed during the education phase, which might be that they object to their sleep being interrupted for report, they dont understand the medical jargon, or they dont want their family to overhear the report. Other barriers will be addressed as they are identified. Expected Outcomes Once the barriers to compliance are addressed, it is expected that compliance would be at 100% for the nurses to conduct bedside report. This would be measured by a repeat of the twoweek observation period of shift report and confirmed by the Clinical Coordinators daily rounding and patient satisfaction scores concerning communication with nurses. Conclusion The overarching goals of patient safety and patient-centered care are supported through bedside report. The Best Practice Standards for this institution include the expectation that each nurse will conduct N2NBSR with every patient. Furthermore, organizations such as The Joint Commission, The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), the Institutes of Medicine (IOM), and independent groups such as the Robert Wood Johnson Foundation and The Studer Group encourage patient-centered care initiatives such as nurse-to-nurse bedside shift reporting as a part of cultivating a culture of patient safety and

QI INITIATIVE: INCREASING STAFF PARTICIPATION IN N2NBSR

enhanced communication (Studer, 2012). With these goals and endorsements in mind, we can do no less than strive for 100% participation in bedside shift report.

QI INITIATIVE: INCREASING STAFF PARTICIPATION IN N2NBSR

References Griffin, T. (2010). Bringing change-of-shift report to the bedside: A patient- and family-centered approach. Journal of Perinatal and Neonatal Nurses 24(4). Hagman, J., Oman, K., Kleiner, C., Johnson, E. & Nordhagen, J. (2013). Lessons learned from the implementation of a bedside handoff model. Journal of Nursing Administration 43(6). doi: 10.1097/NNA.ob013e3182942afb Institute of Medicine. (2001). crossing the quality chasm: A new health system for the twentyfirst century. Washington, DC: National Academics Press. Reinbeck, D.M., & Fitzsimons, V. (2013). Improving the patient experience through bedside shift report. Nursing Management 44(2). doi:1031097/01.NUMA0000426141.68409.00 Revere, A. & Eldridge, N. (2007). JCAHO national patient safety goals for 2007. Topics in Patient Safety 7(1).Retrieved from http://www.patientsafety.gov/TIPS/Docs/TIPS_JanFeb07.pdf Sand-Jecklin, K. & Sherman, J. (2013). Incorporating bedside report into nursing handoff: Evaluation of change in practice. Journal of Nursing Care Quality 25(2). doi: 1031097/NCQ.0b013e31827a4795 Studer Group. (2012). The Nurse Leader Handbook: The Art and Science of Nurse Leadership. Gulf Breeze, FL: Fire Starter Publishing. Wakefield, D.S., Ragan, R., Brandt, J. & Tregnago, M. (2012). Making the transition to nursing bedside shift reports. The Joint commission Journal on Quality and Patient Safety 38(6). Yoder-Wise, P.S. (2011). Leading and Managing in Nursing. (5th ed.). St. Louis, MO: Elsevier Mosby.

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Grader Feedback6/18/13 9:26 PM

Dennie: Excellent job on the assignment. I enjoyed reading your assignment; quite intrigued by the content and subject matter. Thank you for the extensive supportive research; it clearly supported your work. I believe one thing that we can take from this particular assignment is that regardless of the topic we choose, there is always opportunity in quality improvement including process improvements (if you will). Again, excellent job! Thanks, Eppie